In a June 15 letter to the American Psychiatric Association (APA), ASHA commented for a third time on the proposed content of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). And although some of ASHA's proposed changes have been incorporated into the DSM-5, ASHA leadership maintains that key areas of the DSM-5 are still in need of fundamental revision.
The DSM, published by the APA, is the standard classification of mental disorders used by a wide variety of professionals in clinical and community settings in the United States and other countries. The APA is coordinating with numerous professional organizations on the current revision, a massive project begun in 1999.
ASHA questioned the inclusion of "communication disorders" in a manual of mental disorders (see "DSM-V Revisions To Move Forward," The ASHA Leader, January 17). In collaboration with other organizations, including the Canadian Alliance of Audiology and Speech-Language Pathology Regulators, the Canadian Association for Speech-Language Pathologists and Audiologists, the Comité Permanent de Liaison des Orthophonistes-Logopèdes de l'Union Européenne, and Speech Pathology Australia, ASHA sent a strong message to the APA that although psychological responses to communication disorders may indeed occur, communication disorders do not necessarily have a psychological origin.
"This message to the proposed DSM-5 revision is an excellent example of multi-nation collaboration on behalf of those we all serve," said Arlene Pietranton, ASHA chief executive officer. "We sent a powerful message supported by four other organizations from around the world."
Because SLPs have the appropriate education and expertise to provide services specified in their scope of practice, ASHA suggested that "speech-language pathologists" be added to any listing of professionals who may use the revised manual. "The failure to acknowledge the role of speech-language pathologists in the DSM-5, and the inclusion of communication disorders under the rubric of mental disorders, is a disservice to ASHA members and those we serve," said ASHA President Shelly Chabon in a letter to Dilip V. Jeste, APA president. "Ensuring that individuals with communication disorders have access to the services they need from those professionals who have the education and credentials to provide such services is intrinsic to our mission."
ASHA made specific recommendations in several areas. More information—and a rationale for each of the proposed changes—can be found in the comments on the DSM-5 webpage on the ASHA website.
- Specific Learning Disorder: Change DSM-5 terminology from "Specific Learning Disorder" to "Learning Disability" or "Specific Learning Disability"; include "Language (listening and speaking)" as a specifier under Specific Learning Disorder, as well as a statement that language can be in any modality; add to assessment batteries the use of norm-referenced, criterion-referenced, or curriculum-based performance measures of achievement, and observations and data from a student's response to intervention and instruction.
- Intellectual Developmental Disorder: Change DSM-5 terminology from "Intellectual Developmental Disorder" to "Intellectual Developmental Disability"; eliminate the severity grid; add assessment of support needs (such as alternative and augmentative communication or communication partners).
- Autism Spectrum Disorder: Revise the diagnostic criteria to include a fifth diagnostic criterion—"Deficit in oral language"—for autism spectrum disorder; add "verbal" to the proposed diagnostic criteria; and include a statement about cultural variation.
- Language Disorder: Omit "Specific Language Impairment" as a specifier of a language disorder.
- Social Communication Disorder: Do not include or refer to a social communication disorder as a distinct diagnostic category. It should be part of the definition of a language disorder.
- Mild/Major Neurocognitive Disorders: Use one term—"neurocognitive disorder"—and do not distinguish between two levels of severity; clarify the diagnostic criteria.
- Neurocognitive Disorder Due to Traumatic Brain Injury: Use the definition of TBI provided in the DSM-IV-TR; severity scale should apply to the neurocognitive aspects of TBI and not just to the etiology.
ASHA also provided input on the DSM-5's new Cultural Formulation Interview questions, suggesting phrasing to achieve better health literacy, urging the use of one questionnaire for all patients, and recommending field testing the questions to ensure they elicit the needed cultural information.
ASHA objected to including the word "biological" in the proposed definition of "Mental Disorders," because this phrasing appears to equate mental and neurological disorders—an inappropriate definition that may contribute to misdiagnosis and inappropriate treatment.
ASHA recommended that motor speech disorders, voice disorders, and resonance disorders not be included in DSM-5. These disorders are physiological problems rather than mental or developmental disorders. Therefore, ASHA considers inclusion of such disorders in a manual of mental disorders and in a section on neurodevelopmental conditions to be unwarranted. Motor speech, voice, and resonance disorders are described in the International Classification of Diseases, Ninth Revision (ICD-9-CM) under chapter 16, Symptoms, Signs, and Ill-Defined Conditions, where most organic speech, language, and voice disorders are classified.
The final comment period for the DSM-5 closed June 13. For current information on the DSM-5 revision, visit the DSM-5 website.
For more information, contact Diane Paul, director of clinical issues in speech-language pathology, at firstname.lastname@example.org. She serves with Amy Wetherby (chair), Nickola Nelson, and Mabel Rice on the DSM-5 Communication Disorders Advisory Committee.